and can leave the skin relatively unharmed between the point of entry and exit. Evaluating electrical injuries and in particular, differentiating between them and injuries from electric arcs (which only cause heat) is extremely difficult, and as a result, should only be carried out in a specialized center. Patients should only receive outpatient treatment in exceptional cases for tiny burns from sparks. Contact with household electricity should always result in shortterm observation of the patient’s heart and circulatory functions in order to detect any resulting complications. The electricity’s entry and exit points are usually deep lesions with a poor prognosis for healing. In this case, inpatient treatment is usually also indicated.

Self-inflicted or externally-inflicted injuries

If the burn or scald is the result of a self-inflicted injury or one inflicted by a third party, the person must receive inpatient treatment regardless of the extent of the local damage. Even when dealing with small injuries, this is an important step as it serves to remove the patient from the dangerous place and determine the exact cause of the trauma. In these cases it can sometimes be necessary to get family members, caretakers, and even the police involved. Offering the injured person outpatient treatment is not indicated, because in these types of cases further injuries to the patient are to be expected [23].

Chemical burns

The effect of corrosive chemicals to our skin causes coagulative necrosis if the chemical is an acid. Depending on the length of exposure, these chemicals can cause different degrees of damage similar to burns [22]. On the other hand, bases more often cause liquefactive necrosis, which causes the tissue to liquefy. Similar to acid, this can also result in varying degrees of damage. Chemical burns caused by hydrofluoric acid represent a special case, since after penetrating the skin, the acid often causes necrosis which stretches deep into the tissue and even destroys bone.

The first main step when treating such injuries is to rinse them with copious amounts of water. This dilutes the damaging substance while at the same time washing it out. Antidotes are also used in special cases, for example when treating chemical burns caused by hydrofluoric acid. In this case, the affected area is coated with calcium gluconate and if the extremities are injured, calcium gluconate is also administered intra-arterially [22]. When providing initial treatment it is often difficult to evaluate the effects of a chemical burn as well as its progression, which means that in this case the injured person must be monitored at close intervals after receiving inpatient treatment, even if injuries appear to be minor. People with chemical burns caused by hydrofluoric acid must always be transferred to a specialist clinic to receive inpatient treatment.

Treatment

Initial treatment

There is no question that immediately cooling the tissue to under 44 degrees Celsius after a trauma is sensible, since allowing the tissue to remain at a high temperature would lead to even more extensive tissue necrosis. The method used to cool the tissue as well as the length of time the tissue should be cooled are the subjects of much debate, however.

It is generally recommended to use cool tap water for a period of up to 30 minutes. However, when doing so one must take care of not to cool too large of an area due to the risk of hypothermia. Cooling the area not only reduces tissue temperature to more normal levels but further stabilizes mast cells. As a result, the release of inflammatory mediators is decreased, pain is alleviated, and edema is reduced [24]. Using extremely cold water and/or ice packs or ice should be avoided, since the resulting reduction in capillary circulation can actually increase the amount of tissue damage.

Based on the aforementioned, cooling a burn wound is more of an immediate emergency procedure to be carried out at the location of the accident, and as a result, represents a method of first aid which one can carry out themselves or can be provided by a layperson. On the other hand, in the scope of initial medical treatment by a physician, cooling the burn wound is only recommended when tissue is severely overheated [25].

Pain therapy

Burns are extremely painful, especially superficial burns affecting the dermis. This strong burning pain can continue for several hours and can also reappear due to sticking dressings and/or repeatedly manipulating the burn wound while providing treatment or changing bandages. Deep burn wounds are often less sensitive and are associated with reduced pain due to the destruction of the skin’s nerve receptors. Providing sufficient pain therapy represents an important first step in treating all burns [26].

Providing non-steroidal anti-inflammatory drugs (NSAID) at an early stage should be considered. Drugs containing acetylsalicylic acid should not be used due to coagulopathy resulting from platelet function disorders.

When treating kids, the use of an age-appropri- ate and weight-appropriate dose of acetaminophen is recommended. If this first stage of pain therapy is not sufficient, a combination using codeine or metamizole or an orally-administered opiate should be considered. Significantly agitated patients benefit from the use of a fast-acting benzodiazepine, which will have a sedative effect. For the first few days a sufficient number of analgesics should prescribed as the standard medication. Prescribing an increased dose for bandage changing procedures, physical therapy, and/or for nights may be necessary. When it comes to the use of analgesics, one must always consider the patient’s additional alcohol intake or, if applicable, factor other addictive disorders into a calculated pain therapy program.

If a patient has significant and/or uncontrollable pain, they should not receive outpatient treatment but rather be transferred to an inpatient setting. Once there, pain medication should be administered intravenously. The use of local anesthetics, or rather injecting local anesthetics into the area of the burn wound should not be carried out within the course of burn treatment.

Local treatment

Burn blisters

Particularly in the case of dermal burns, part of the epidermis rises up in the form of a thin blister. In deeper burns, the necrotic area is thicker, which

means that these blisters usually do not form. The substance inside the blister shows the disruptive effect on wound healing [27]. Nevertheless, an intact blister represents a closed wound, which reduces the risk of infection. As a result, the proper method of handling blisters is a subject of much debate. In our own procedures, with the exception of extremely tiny blisters and thick blisters located on the palms of the hands or the soles of the feet, we completely remove all blisters. It is imperative that all blisters in the area to be treated are completely removed, particularly when planning to use modern wound dressings. Since torn blisters do not offer any protection against infection, the wound needs to be treated with topical substances anyway. Similarly, in order to prevent the hair from sticking to the wet wound, any body hair remaining in the wound area must also be removed, with the exception of the eyebrows.

Debridement

As previously mentioned, all burn wounds must be debrided. Removal of the blisters is carried out either using scissors and tweezers, with a moist compress, or a soft brush. Manipulating the wound in this way requires the patient’s pain to be sufficiently numbed, and as a result, such procedures are often carried out while the patient is anesthetized. The goal of this procedure should always be to thoroughly clean the wound bed. This is the only way to properly evaluate the depth of the burn as well as initiate proper wound treatment procedures. Mild liquid soap, or better yet, Lavasept or octenide solution are perfectly suitable for cleaning contaminated wounds. In our procedures, we completely refrain from using products which contain iodine to avoid contaminating our waste water [28]. Extremely adhesive substances such as tar, asphalt, or lubricants can be removed using baby oil or butter.

Surface treatment/Topical substances

The rationale for using topical substances in the treatment of burns is primarily to reduce superinfection of the burn wound. In addition, particularly when it comes to the superficial wounds which are usually the focus of outpatient treatment, these sub-

stances should not slow down reepithelialization. Furthermore, priority is given to the patient’s comfort with an almost painless or truly painless application [29].

A number of substances more or less fulfill these criteria and as a result, are suitable for use when treating superficial burn wounds.

Povidone-Iodine

Povidone-Iodine (PVP-I) is effective against most germs which are relevant to the treatment of burn wounds. However, it is important to take note of the substance’s considerable cytotoxicity, which can slow down the wound healing process [30]. Furthermore, its absorption toxicity must also be considered. A contraindication exists in case of hyperthyroidism, dermatitis herpetiformis, hypersensitivity to iodine, as well as use before and after radioiodine therapy (Kramer). In our procedures, ointments containing iodine are only used for deep burn wounds under consideration of the contraindications, since the iodine also has an drying effect on the skin which makes it easier to operate on later. Liposome capsules filled with PVP-I in hydrogel form are an affordable galenical which have a reduced iodine content and are more gentle on the wound. As a result, this iodine preparation (Repithel, Mundipharma GmbH, Limburg, Germany) is also suitable for follow-up treatment of transplanted wounds.

Silver sulfadiazine (Flamazine ) and other silver products

Dressings containing silver have been used to cover wounds since ancient times. The free silver ions can damage bacteria cell walls, and silver sulfadiazine bonds with bacterial DNA. This means Flamazine has a bacteriostatic and bactericidal effect, and is suitable for all burn wounds [31]. However, when using Flamazine, as is the case with all silver ion applications, one must always take its cytotoxic effect (with slowed wound healing) into consideration. In addition, Flamazine forms a residue on the wound (“Flamazine eschar”) which makes evaluating the wound after several days significantly more difficult. Due to these drawbacks, we completely refrain from using Flamazine in our own procedures. New products are currently offered like Acticoat and

Mepilex Ag . There benefit is that do not require daily dressing changes like Flammazine, but the use of silver products are more and more under discussion.

Polyhexanide (PHMB)

In the past few years, a new topical antiseptic has gained popularity in burn wound treatment thanks to it also having a wide range of effects and extremely low cytotoxicity when it comes to keratinocytes and fibroblasts. Polyhexanide was primarily sold as a raw material under the name Lavasept by the company Fresenius, and customers had to prepare ready-to- use gels and solutions themselves. But since then a number of manufacturers have created such ready- to-use solutions or gel forms of polyhexanide which, as a result, are now available for use in burn wound treatment. The advantage of the limpid gel or limpid solution is that it doesn’t change the color of the wound, which means the wound can be evaluated at any time while providing treatment. Because it is highly diluted, Lavasept gels can be used in the wound area not only in short-term but also longterm applications. The applied solutions or gels do not cause any pain, which means children can tolerate them as well. Polyhexanide is the first known wound antiseptic with a selective mechanism of action. This is due to a strong effect on the acidic phospholipid bacterial cell membranes but only a slight effect on neutral phospholipid human cell membranes. This explains polyhexanide’s extremely minimal cytotoxicity. Due to its molecule size, based on the current state of knowledge we can assume that polyhexanide is not absorbed by the body and as a result, only has an effect on the area of application [32].

In day-to-day clinical practice, gel preparations which use polyhexanide have proved to be of great value in the moist treatment of superficial burn wounds. We use the solutions both as a gentle method of disinfecting wounds when providing initial treatment and as part of subsequent dressing changes.

Obsolete and unnecessary substances

Dyes and organic mercury compounds should be viewed as obsolete and unnecessary for use as burn wound antiseptics. In addition, hydrogen peroxide is